Pre-Hematopoietic Stem Cell Transplantation Rituximab for Epstein-Barr Virus and Post-Lymphoproliferative Disorder Prophylaxis in Alemtuzumab Recipients

Epstein-Barr virus (EBV) reactivation and EBV-related post-transplantation lymphoproliferative disorder (PTLD) are often fatal complications after allogeneic hematopoietic stem cell transplantation (allo-HSCT). The risk of EBV reactivation may be mitigated by depletion of B cells with rituximab. Starting in January 2020, allo-HSCT recipients undergoing T-cell depletion with alemtuzumab received 1 dose of rituximab before transplantation. The objective of this study was to evaluate the cumulative incidence of EBV reactivation and EBV-PTLD in recipients of allo-HSCT and in vivo T-cell depletion with alemtuzumab who received pre-HSCT rituximab compared to patients who did not. This was a single-center retrospective analysis of adult patients who consecutively received an HLA-identical allo-HSCT between January 2019 and May 2021 and in vivo T-cell depletion with alemtuzumab. Patients were included in the rituximab cohort if they received rituximab within 6 months before their transplantation. The primary endpoint was incidence of EBV reactivation at day 180 among those receiving pre-HSCT rituximab versus those not receiving rituximab. Secondary endpoints included cumulative incidence of EBV-PTLD at 1 year, time to engraftment, immune reconstitution, and incidence of infections and acute graft-versus-host disease (aGVHD) at day 180. Eighty-six consecutive patients who received an allo-HSCT with alemtuzumab T-cell depletion were reviewed; 43 patients who received pre-HSCT rituximab after our protocol modification were compared to 43 patients who did not receive pre-HSCT rituximab before this change. Median age was 57 (interquartile range [IQR] 40-69) years, and the majority of patients had acute myeloid leukemia or myelodysplastic syndrome. Baseline characteristics were similar between the cohorts. EBV reactivation at day 180 occurred in 23 (53%) patients without prior rituximab exposure versus 0 patients with pre-HSCT rituximab exposure (P < .0001). Similarly, 6 patients without prior rituximab exposure developed PTLD at 1 year compared to no cases of PTLD among patients receiving pre-HSCT rituximab. There was no difference in neutrophil engraftment, incidence of infections, or aGVHD at day 180 between the 2 cohorts. There was a delay in time to platelet engraftment in the rituximab cohort (median 16 [IQR 15-20] days versus 15 [IQR 14-17] days; P = .04). Administration of pre-HSCT rituximab before allo-HSCT in patients receiving T-cell depletion with alemtuzumab was associated with a significant decrease in the risk for EBV reactivation and EBV-PTLD, without increasing aGVHD or infection rates.

Reasons for declining a pharmacist-led telehealth study among oncology patients initiating oral anti-cancer drugs

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Background: During the COVID-19 pandemic, remote cancer care, and video communication in particular, has become increasingly common in the context of routine visits and clinical trials. Though this medium has the potential to augment patient-provider communication, telehealth also raises concerns about the digital divide promoting disparities in access to cancer care. In this study, we surveyed oncology patients who declined to participate in a pilot study looking at a one-time pharmacist-led video visit for patients initiating oral anti-cancer medications to evaluate their primary reason for declining the intervention. Methods: Between June 2021 and June 2022, we conducted a prospective survey among adult oncology patients at Columbia University Medical Center (CUMC) who declined a pilot study looking at a video visit intervention for patients initiating oral anti-cancer medications to assess the primary barriers to participation. The survey categorized specific reasons for decline into telehealth-related barriers (no access to electronic device, inability to navigate video visits specifically, patient preference for in person care) and trial-related barriers (patient too tired/unwell, no time to participate, not interested in this study specifically, not interested in clinical trial participation in general), and patients were asked to select the primary reason for declining among the list of options. Results: Twenty-three patients completed the survey (82% completion rate). Among 23 respondents, 9 patients (39%) described a technology-related barrier to participation, including 7 (30%) who owned a mobile device with video capacity, but did not know how to use video technology well enough for the visit, 1 (4%) who did not own a device with video capacity, and 1 (4%) who preferred in person visits. Fourteen respondents cited a reason unrelated to telehealth for declining participation, including 7 (30%) who did not feel the study would benefit them, 3 (13%) who did not have time, 2 (9%) who were too tired to participate in a study, and 2 (9%) who were not interested in participating in any kind of clinical trial. Conclusions: Video-based telehealth visits have become increasingly common in routine cancer care and clinical trials. Among oncology patients who declined participation in a pilot study looking at a pharmacist-led video consultation, over a third cited telehealth-related barriers to participation, the majority of whom had a mobile device, but did not know how to use video technology well enough to participate. Focusing efforts on training patients to use technology, particularly video communication, may help address the digital divide in cancer care.

Extended letermovir administration, beyond day 100, is effective for CMV prophylaxis in patients with graft versus host disease

BACKGROUND

Cytomegalovirus (CMV) reactivation is associated with significant morbidity and mortality after an allogeneic hematopoietic cell transplant (AHCT), and graft versus host disease (GVHD) increases the risk of CMV reactivation. Letermovir is approved for CMV prophylaxis in CMV-seropositive patients, but has only been studied through day 100 post-transplantation in the registration trial. Its efficacy in preventing CMV in patients with GVHD requiring treatment beyond the day 100 milestone has not been studied.

METHODS

We retrospectively analyzed all patients who underwent an AHCT at a single center over a period of 24 months, and identified a cohort of 20 patients who received extended duration of letermovir (beyond 100 days) after the diagnosis of GVHD. The primary end point was the incidence of clinically significant CMV infection, defined as onset of CMV disease or initiation of preemptive therapy with alternative antiviral agents.

RESULTS

In this high-risk cohort, only one patient (5%) developed a clinically significant CMV infection, requiring preemptive therapy. No patients developed CMV organ disease. Three additional patients developed CMV viremia of ≥150 IU/mL while on letermovir and after the onset of GVHD, and none required additional treatment. Receipt of post-transplant cyclophosphamide (PTCy) and low CD4 count after the development of GVHD were associated with breakthrough CMV viremia while on extended duration letermovir.

CONCLUSIONS

Extended duration letermovir was efficacious in preventing clinically significant CMV infections in patients with GVHD.

Review of Melatonin Supplementation for Sleep Disorders in Pediatric Special Populations

OBJECTIVE

To determine which pediatric populations, if any, benefit from exogenous melatonin supplementation.

METHODS

PubMed was utilized for the purposes of this systematic review. The studies selected evaluated melatonin use in pediatric special populations and included randomized controlled trials, crossover studies, and meta-analyses. Each study's objectives, measures of outcomes, and dosing strategies of melatonin were reviewed along with the results and author's conclusions.

RESULTS

Our analysis of the available data offers mixed results and recommendations with regard to the decision of whether to add supplementation of melatonin.

CONCLUSION

With further regulation of melatonin supplements, it may be plausible to hold larger, multicenter trials and come to a firm recommendation in the future. At this time, we believe that the benefit of exogenous melatonin supplementation outweighs the risks of adverse events and therefore would recommend its use in aiding patients in improving their sleep. Exogenous supplementation with melatonin should be used at the physician's and patient's discretion.